Comprehensive Rehabilitation Consultants (CRC)

Nurse

• Deliver Transitional Care and Chronic Care Management services
• Review EMR records to inform initial outreach and care plan focus areas
• Perform comprehensive assessments of physical and psychosocial risk factors
• Identify and address barriers to individual patient needs
• Communicate assessment findings, care plan goals, interventions, and outcomes to providers, patients, and caregivers
• Monitor patients’ ED visits and acute stays
• Perform post-discharge follow-up calls and continuously assess readmission risk
• Use motivational interviewing to promote patient engagement and self-management skills
• Provide chronic disease education and symptom-management teaching
• Communicate proactively with providers regarding changes in patient status and necessary referrals or orders
• Document care plans, clinical interventions, and outreach in the care management software system
• Develop and maintain professional working relationships with assigned providers and care management team members

LPN Care Coordinator